Maintaining secure patient records is critical in ensuring compliance, protecting sensitive information and improving administrative efficiency within healthcare practices. As technology advances and data management becomes increasingly complex, healthcare providers must adopt robust strategies to safeguard records while maintaining accessibility for authorised personnel.
This article explores essential best practices for achieving high-quality, secure patient record management, enabling healthcare organisations to optimise operations and deliver better patient care.
Why are secure patient records so important?
A patient record holds confidential and sensitive information so it is imperative that they remain secure.
High-quality records are complete, accurate and legible, and when properly stored and secured, can be shared efficiently among healthcare providers with the patient's consent. Secure patient records support:
- Competent decision making
- Effective communication
- Trust between practitioner and patient, and
- Continuity of care
How can secure patient records be sustained?
Systems and management
The quality of your patient records is dependent on the quality and suitability of the health record system within your organisation. A health record system specifies the way patient information is collected, recorded and stored. It includes the policies and procedures a healthcare organisation will follow, staff training and education on the system, initial system implementation and ongoing management.
Some health organisations will give ownership of the entire system to a specific staff member, who takes on the patient record strategy and management responsibilities.
Policies, procedures and protocols
Your governance structures should be documented, periodically evaluated, and adjusted to remain effective and compliant. Regular audits, employee compliance checks, and training are also essential to ensuring that your system operates as intended.
Your policies, procedures and protocols should cover:
- Retention requirements
- Disposal requirements
- Digital and manual file storage and transport systems
- How clinical information is recorded
- Access to records at the point of care
- Emergency access to records when a patient is unable to consent
- What information is recorded to effectively monitor the quality of care
- Availability of formal reports, for example, imaging and pathology tests
- How changes to the record are authorised
- How and when compliance audits are undertaken
- Compliance with the relevant standards and professional and legislative requirements.
Training and education
While staff training often begins with the implementation of a new system or during onboarding, it should be an ongoing process. All employees, both clinical and administrative, should regularly participate in training sessions to reinforce the importance of maintaining secure records and how the organisation's system supports this.
Staff education may include sessions on:
- Identifying the information required for a patient record
- Records management standards (eg. retention, confidentiality, disposal and more)
- The risks of incorrect information being recorded
- Software features if electronic records are stored digitally
Consider knowledge gaps that exist in your organisation so you are able to address the specific training needs of your employees. If you're unsure what gaps persist, ask your staff for their input.
Security and compliance
Given that information about a person's physical or mental health and well-being is both private and sensitive, it's imperative that your patient records are securely managed. Beyond mitigating data security risks, it is also the responsibility of the organisation to comply with relevant jurisdictional legislation.
With electronic records management now commonplace, there is also a rise in concerns regarding how secure information is when accessed across computers and mobile devices like smartphones or tablets. Naturally, the secure exchange of information—whether manual or digital—between practitioners remains a pressing concern for many. To ensure accurate records, document and information security, compliance and patient trust, healthcare organisations must implement effective security measures to protect the confidentiality of patient data.
The role of technology in securing patient records
The right technology can significantly improve the accuracy and security of patient records. Additionally, implementing modern software solutions can streamline administrative tasks, making processes faster and more efficient.
Electronic Content Management (ECM) or Electronic Health Record software (EHR) automates the documentation, storage and retrieval of high-quality patient records. EHR software facilitates efficient data entry, minimises the need for manual paper records, produces up-to-date patient histories, automates diagnosis and code selection, decreases or completely eliminates transcription costs and decreases time spent retrieving patient information.
A suitable ECM solution will enable your staff to quickly and easily access records while supporting your organisation to provide relevant, accurate, up-to-date and complete patient information. Some of the other benefits of ECM software include:
- Securely sharing digital information with patients and other healthcare organisations
- Enhancing communication with patients
- Empowering safer and more reliable diagnosing and prescribing
- Promoting legible, complete and accurate documentation
- Enabling the privacy and security of patient data
A new ECM will change how people work and manage documents across your organisation. It's not an easy or quick decision to make, but our Enterprise Content Management Checklist will help you consider your options and identify the right ECM to meet your business needs.
